Burnout and wellbeing in mental healthcare staff: Our review

It was an article that started life as a conversation. We sat around a table in March 2016, discussing mental healthcare staff wellbeing. Someone pointed out the increase in burnout they had seen in mental health staff in the services they worked with; someone else spoke about the unique demands of working in mental health care settings, and how staff burnout may impact patient care. It felt like we were tapping important issues; etching out a line of argument we had not seen articulated in any academic articles we had read. Then I heard myself pipe up, “This feels like a paper. We should write a paper. I’ll draft it”.

Famous last words. As I left the room my enthusiasm waned a little. Had I really just volunteered to write another review?

Getting into the data
I knew I was going to need to access original data from government sources to build the case, which was new for me. I scoured NHS Digital and other sites, entering the numbers into excel files in order to plot graphs. These told me that the proportion of NHS  staff feeling unwell due to work-related stress had risen by 9% in 8 years (from 28% in 2008 to 37% in 2016; Figure 1a), and double the number of NHS staff had said they were leaving because of poor work– life balance in 2015 compared with 2011 (Figure 1b). I was stunned.

Figure 1

Figure 1. Percentage of staff reporting having felt unwell due to work-related stress on the NHS staff survey. (Source: NHS staff survey data; www.nhsstaffsurveys.com) (A) and number of staff citing poor work-life balance as their reason for leaving their NHS post. (Source: NHS Digital; https://data.gov.uk/dataset/nhs-workforce-reasons-for-leaving) (B).

Are these problems just in the UK?
The NHS has suffered significant underfunding for several years (Kingsfund, 2017) which has been a cause of staff stress, so I wanted to check whether these problems may be NHS-specific or similar in other countries. I found relevant data provided by the US Bureau of Labour Statistics (2017). Given the vast differences between the organisation of UK and USA healthcare provision it was an interesting point of comparison. This data suggested workers in healthcare support occupations take the most sickness absence of all employees, with rates 50% higher than private sector employees. It was clear that these patterns were not UK specific.

Are they any differences between staff working in mental healthcare and other settings?
Curious to compare mental healthcare staff with healthcare staff in other settings, I emailed NHS Digital to get a breakdown of sickness absence rates by trust type. These told me that mental healthcare staff are off work due to sickness on more days than the overall average for healthcare staff, and on more days than those in both acute trusts and primary care (Figure 2). Mental healthcare staff also more frequently cited anxiety, stress, depression and other mental health problems as the reason for this absence.

MH FIg 2

Figure 2. Sickness absence rate by trust type. (Source: NHS Digital: http://www.content.digital.nhs.uk/catalogue/PUB22562).

It occurred to me that the proportion of different types of staff varies across trust type. Some trusts employ relatively more doctors, and others relatively more allied health staff (such as occupational therapists and physiotherapists). What if this variation in staff type explained the variation in sickness absence? To test this, I restricted the analysis to first doctors, then nurses. It didn’t make a difference. In doctors in acute trusts, 17% of absences were in this category, compared with 26% in doctors working in mental health. In nurses in acute trusts, 18% were in this category, compared with 25% in mental health nurses (NHS Digital, 2017). It was quickly becoming apparent that the concerns we had raised in our conversation and the observations of members of the authorship team were backed up by hard data.

Impact on patient care
In order to consider the impact these high rates of stress may have on patient care, my co-authors and I reached into our knowledge of the general healthcare literature. A previous systematic review we had completed (Hall et al., 2016) found that high staff burnout is linked with greater risk of medical errors happening (or poorer patient safety) across healthcare settings. Medical errors can include being prescribed the wrong amount of a medication by your family doctor, being administered a medication you are allergic to by your nurse in hospital, or even being operated on the wrong body part by your surgeon. As expected, when we searched for studies investigating this area in mental healthcare staff a similar pattern emerged. For example, Brady et al. (2012) found that running a mindfulness-based-stress-reduction intervention with mental health staff improved patient satisfaction scores and decreased rates of patient safety events during the 3 months after the intervention. However, there was a disappointingly small amount of research linking healthcare staff wellbeing and burnout with patient care in mental health, and more is needed.

What about interventions?
There were also fewer studies looking at burnout and wellbeing interventions in mental healthcare staff than other staff groups, but I was pleased to find a recent systematic review and meta-analysis by Kimberley Dreison and her colleagues (2018) focused specifically on burnout interventions in mental healthcare staff. This review identified 27 studies. Interventions included stress management workshops, clinical supervision, and staff training. Overall, interventions were effective but only led to small improvements.

What type of interventions are most effective?
Interestingly, when interventions that focused on individual staff members (e.g., psychological therapy) were compared with those that focused on organisational changes (e.g., introducing staff support groups), individual-focused interventions were more effective. However, when staff training and education interventions were separated out from other types of organisational interventions, they led to greater improvements than individually focused interventions for overall burnout scores. This suggests that training and education interventions may be the best place for future research into burnout reduction in mental healthcare staff to focus on. It also suggests that simple comparisons between individually-focused and organisationally focused interventions could be misleading.

What now?
The purpose of the review was to produce recommendations for moving research and practice in this area forward. In the end, there were 4 of these:

  1. Ground interventions in the research literature: When developing burnout interventions, first understand what the causes of burnout are. Design your intervention to address this. Overall, the research literature suggests that poor staffing ratios, the emotional demands of caring for complex patients, lack of leadership and lack of training are all burnout contributors. Furthermore, draw on what the research tells us is likely to be effective. The best evidence at present suggests that staff training interventions may be particularly effective for reducing overall burnout.
  2. Increase the value of interventions: We know that staff burnout is consistently linked with quality and safety of patient care. It is also likely that these two operate in a feedback loop; not being able to provide high quality care is probably detrimental to staff burnout. Developing interventions which simultaneously reduce staff burnout and enhance care quality may meet two needs at once and be self-reinforcing. Again, staff training interventions would tick this box.
  3. Build bridges between universities and healthcare organisations: Partnerships between universities and healthcare organisations can help identify new and relevant topics for research, ensure studies meet current service and patient needs and help results to have a greater impact in the real world.
  4. Engage healthcare staff by emphasising the positives: There is a perceived stigma linked with admitting poor mental wellbeing in healthcare staff. Staff may fear that disclosure could cause career damage or put their professional registration at risk. As such, rather than offering burnout interventions as a fix for those who are struggling, emphasise the additional benefits that participants may reap. These include increased job satisfaction, life satisfaction, relaxation, and improved physical health. Be clear that interventions are not for the suffering but those who want to thrive in their work.

 

The article is published in the International Journal of Mental Health Nursing. To read the paper, follow this link.

 

References

Brady, S., O’Connor, N., Burgermeister, D. & Hanson, P. (2012). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48, 129–137.

Bureau of Labor Statistics (2017). Absences from Work of Employed Full‐Time Wage and Salary Workers by Occupation and Industry. US Department of Labour. [Cited 18 November 2017]. Available from: https://www.bls.gov/cps/cpsaat47.htm

Dreison, K. C., Luther, L., Bonfils, K. A., Sliter, M. T., McGrew, J. H., & Salyers, M. P. (2018). Job burnout in mental health providers: A meta-analysis of 35 years of intervention research. Journal of Occupational Health Psychology, 23(1), 18-30.

Hall, L. H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE, 11, e0159015.

NHS Digital (2017). Sickness Absence Full Time Equivalent Days Lost by Staff Group, Organisational Type and Reason for Absence. Dataset provided by the Health and Social Care Information Centre on request on 24th April 2017.

How should you tell a parent that their baby has a limb difference? Our study

Put yourselves for a moment in the shoes of a sonographer, conducting an ultrasound scan on a pregnant woman. Perhaps her partner is there, and they are excited, smiling, and asking you the gender of their baby. Suddenly you notice an unexpected finding on the baby’s left arm; you can’t see his hand on this side. Perhaps it’s tucked just out of sight, but you can’t be certain.  He may be missing his hand. What would you do next? What should you say?

Make no assumptions

In the past this question has been answered too quickly. It has been assumed that the answer can be drawn from either 1) the sonographer’s personal experiences at work or 2) from research into how to ‘break bad news’ in other areas of healthcare, like cancer services. Both these assumptions are seriously flawed.

Parents’ reactions may be misleading

The first assumption is flawed because parents do not initially react based on how well the sonographer communicates this information. Instead, after hearing this news parents go into shock (Mckechnie et al., 2016). This means that the healthcare professional may do a great job of communicating the news and find the parents are extremely upset. On the other hand, they may do a terrible job and find the parents seem quiet and calm. The bottom line is that parents’ reactions at the time of the event are not a good indicator of a healthcare professional’s communication skills.

This experience is unique

The second assumption is flawed because delivering this news is different to delivering news in any other area of healthcare. In other areas of healthcare, the focus has been on ‘bad news’ (Baile et al., 2000), and this is not bad news, it is simply unexpected news. It also comes without warning; the parents are watching the sonographer’s face as they do the scan, and know as soon as something is out of the ordinary. Guidelines for delivering news in other areas of healthcare are not appropriate to apply in this situation.

Our research

It won’t come as a surprise then that in a survey we conducted in 2014, parents reported very low satisfaction with their experience of being told their baby had a limb difference (Johnson et al., 2016). To explore this area some more, we recently interviewed 20 parents (nine fathers, 11 mothers) who had had a baby with a limb difference in the UK in the last five years (for the full paper see HERE). Eight of these parents were told the news at an ultrasound scan, but 12 didn’t know about their baby’s limb difference until they were born. We asked these parents about their experiences of being told the news of their baby’s limb difference and how they thought this could have been improved.

What we found

Parents were keen to take part in the study. They had a range of experiences and while some wanted to participate because they felt things needed to improve, others were grateful for the excellent healthcare they had received at this time. However, all parents felt this was a defining moment in their lives: whether things had been done well or not well mattered. Receiving this news was the start of a journey into the unknown, and good experiences at the start had a lasting influence on how this unfolded.

Shock

In line with previous studies, all parents were shocked to learn their baby had a limb difference, but parents were less shocked when the limb difference was found on an ultrasound scan and they had time to process this news before their baby was born. They were also less shocked and less anxious when they had a friend or family member with a disability.

What parents want

Information about support organisations: Organisations such as Reach helped parents to find the right information and provided a support network. However, most parents only discovered these organisations through extensive online research and would have preferred to be told about these right away by the healthcare professional who told them the news.

Information about limb differences: While most parents wanted as much information as soon as possible about the limb difference, some said they felt overwhelmed and preferred to process the news at a slower pace. All of these parents said that being given written information would have been helpful.

Good communication skills: Parents wanted clear but sensitive communication from their care providers. In contrast to research in other healthcare settings, parents preferred it when healthcare professionals described the limb difference in a no-frills way, for example, “I cannot see your baby’s arm below their elbow on the left side”. Parents didn’t like it when healthcare professionals led into this with a warning sentence, like “I have found something wrong” or “there is a problem”. When this was said, it needlessly increased parents’ anxiety.

A care plan: Most parents felt frustrated about delays in their child’s health care; they described accessing appropriate care as a ‘battle’ and said they would have liked to know what their plan of care was going to be immediately. Only a few parents felt the plan of care they received had been good enough.

Some final pointers for healthcare professionals

If you are a healthcare professional, some final recommendations came out of our research:

Parents don’t like strangers appearing in the scan room: Some parents described being asked to go for a walk and returning to find a second sonographer in the scan room. For one parent, this was enough to trigger floods of tears, as she knew it meant something was wrong. Parents preferred it when they were warned in advance that a second sonographer was going to be invited in, and were given an honest rationale for this (e.g., “I cannot see your baby’s arm, so I need to find someone who is more experienced”).

Show that you care: Several parents said that they know delivering difficult news is hard for healthcare professionals and it is challenging to get this ‘right’. However, if they thought the healthcare professional cared, they tended to view them positively and be forgiving in any missteps in wording or communication.

Don’t panic: Parents appreciated it when healthcare professionals were confident and professional; when instead healthcare professionals communicated their personal shock at the dysmelia diagnosis (e.g., “this has never happened before”), parents felt more anxious and alone in their situation.

Insensitive questions are as bad as insensitive statements: When parents discovered the limb difference at birth, some reported being quickly asked insensitive questions. For example, one parent was being stitched up from her caesarean section when her doctor asked her what drugs/medication she had taken during pregnancy. The implication of questions such as these is that the parent has caused the limb difference by something they have done. Parents who received these types of questions too quickly found they had a strong and lasting negative impact on them.

 

References

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302-311. doi:10.1634/theoncologist.5-4-302

Johnson, J., Adams-Spink, G., Arndt, T., Wijeratne, D., Heyhoe, J., Taylor, P. J. (2016). Providing family-centred care for rare diseases in maternity services: Parent satisfaction and preferences when dysmelia is identifiedWomen and Birth29, e99-e104.

McKechnie, A. C., Pridham, K., & Tluczek, A. (2016). Walking the “emotional tightrope” from pregnancy to parenthood: Understanding parental motivation to manage health care and distress after a fetal diagnosis of complex congenital heart disease. Journal of Family Nursing, 22, 74-107. doi:10.1177/1074840715616603

 

The reference for the paper described in this blog is: Johnson J., Johnson, O., Heyhoe, J., Fielder, C., & Dunning, A. (2018). Parent experiences and preferences when dysemlia is identified during the prenatal and perinatal periods: A qualitative study into family nursing care for rare diseases. Journal of Family Nursing. In press. It can be viewed on the journal website HERE.

What are parents’ experiences when their baby is diagnosed with a limb difference? Our study

What is dysmelia?

Dysmelia is a group of rare diseases involving  limb differences. Rare diseases are those which affect less than 1 in 2000 people, but around 8000 rare diseases exist altogether and over 50 million people in the USA and Europe are affected.

Several rare diseases including dysmelia are diagnosed during pregnancy or shortly after birth. If  diagnosed during pregnancy, parents may need to make important decisions around whether to undergo invasive testing or to receive a termination. In dysmelia, termination rates vary between 20% and 50%. If identified after birth, parents will need rapid access to information and support, to help them care for a baby with a disability. However, little is known about the experiences of parents and how they could be better supported at this time.

Our research

We undertook research into the experiences of parents when their baby was diagnosed with dysmelia (for the full paper, see here). We distributed two surveys online, which were responded to by parents from across the globe. The first survey was completed by 417 parents, and the second survey was completed by 130 parents.

What we found

Results from the surveys indicated that a third of parents received a diagnosis of dysmelia before birth, and two thirds received the diagnosis after their baby was born. On average, parents were less than satisfied with the care that they received (average score of 2.6 on a scale from 1 to 5, where 1 was ‘very dissatisfied’ and 5 was ‘very satisfied’; see Figure 1).

Figure 1

Figure 1. How satisfied parents were with the care they received when their baby was diagnosed with a limb difference.

Only a quarter of parents were given information about organisations they could contact for support (Figure 2), and parents based in Europe were twice as likely to be given this information as parents living elsewhere. This was particularly striking when compared to our finding that over 90% of parents said they would have wanted this information.

Figure-21.jpg

Figure 2. The percentage of parents who received information about organisations they could contact for information and support regarding limb differences.

What parents want

When asked about the information and support they would have liked to receive, 46% of parents said they would have liked information about raising a child with a limb difference and 51% would have liked information about specialist treatment. In terms of support from professionals, 41% would have liked to be referred to a psychologist, and 39% would have liked to speak to a hand/foot surgeon.

One simple improvement healthcare professionals can make

These findings suggest there is a strong need to improve the healthcare provided to parents when their baby is diagnosed with a limb difference. One clear and simple improvement could be to provide information about organisations that parents can contact for support. These findings may also be relevant for other rare diseases which are often identified during pregnancy or shortly after birth.

Four reasons why we need healthcare research (or, why common sense is not enough)

[Authored by Olivia Johnson, Alice Dunning and Judith Johnson]

Healthcare research can feel out of touch and out of step with clinical demands and priorities. It’s usually a slow process, often riddled with delays, and it may not address the immediate questions healthcare staff are asking.

As healthcare researchers, we have been challenged about the point and purpose of our work. After all, we’ve been asked, doesn’t research usually just confirm what we know by common sense, anyway? Aren’t the true advances in healthcare made through common sense clinical observations and logical assumption? Here, we present four reasons why healthcare research is needed (or, four ways that common sense has not been enough).

1. Widely practised treatments based on common sense clinical knowledge have been found to be ineffective (or harmful) when tested by research.

One clear example of this is the use of oxygen therapy as emergency treatment following a heart attack. For over 100 years this was considered common sense and routine, based on knowledge that the blocked artery would prevent oxygen from reaching the heart. However, in 2009 a review of research studies testing this intervention reported counterintuitive results [1]. Rather than compensating for the lack of oxygen to the heart, the review found that oxygen treatment increased, rather than decreased, the size of the area affected by lack of oxygen. These studies have started to raise debate about the guidelines for emergency oxygen treatment, challenging standard healthcare practices and moving this field forwards [2].

Reaching back further in time, in the middle of the 20th Century, we can find a similar example of counterintuitive research results in the work of Ignacio Ponseti. Ponseti was an Orthopaedic Surgeon who began researching Club Foot, a condition where one or both of a child’s feet are turned inwards and downwards. At the time, based on clinical knowledge and common sense, it was widely assumed that Club Foot should be treated surgically [3]. Ponseti, however, began to recall individuals who had had this surgical treatment twenty years later. Contrary to expectation, his research found that many of these patients were suffering from rigid, weak feet [3]. Ponseti delved into the research literature for answers, drawing on papers published as far back as 1872 [4] to develop a treatment based primarily on plaster casts [5]. His results were impressive, suggesting that 71% of feet treated with his method showed a good outcome 5-12 years later [3]. The downside was that his procedure was slow, involving phased treatment that lasted months. It felt counter-intuitive and undesirable compared to a surgical intervention which had much quicker results. Because of this, Ponseti’s approach was regarded as outlandish, and for years many people viewed him as crazy [6].  It wasn’t until the 1990s, when he had produced further promising research results and word began to spread, that his evidence-based approach became the ‘norm’.

A more current example like this comes from the field of miscarriage research [7]. Based on knowledge that the hormone progesterone is key to maintaining a healthy pregnancy, a common sense treatment for women at risk of miscarriage has been to prescribe progesterone supplements after a positive pregnancy test result. However, when it was put to the test in a large-scale study last year, this treatment was not found to be effective. Contrary to expectations, women prescribed progesterone supplements had almost exactly the same risk of miscarriage as women prescribed a placebo version of the hormone [7]. In the absence of promising new interventions for miscarriage, this result was disappointing to the many couples affected by this problem. On the other hand, it could be the evidence that researchers need to spur them on to find new answers. Let’s watch this space!

2. Healthcare research has proved that interventions that are intuitively bizarre can in fact be helpful.

Sometimes the strangest things can help, and without research, it’s hard to see how these kind of treatments would have come to light. One example comes from research into IVF (in-vitro fertilisation), where success rates continue to be disappointingly low. However, recent hope has come from a treatment known as the “endometrial scratch”. As it sounds, this is literally where the inside of a woman’s uterus is scratched prior to undergoing IVF. Although strange sounding, evidence that this may be beneficial first came from research in guinea pigs in 1907 [8]. In the past decade studies have begun to explore this treatment for boosting IVF success rates in humans. When reviewing these studies together, a recently published paper concluded that the endometrial scratch improves IVF success rates in women who have undergone previously failed attempts, who might otherwise have low chances of success [8].

Other counterintuitive treatments have come from research into physical health symptoms which cannot be explained medically. You may initially think that these problems must be rare, and that physical health problems on the whole require a medical intervention targeting the body. However, research has told us that around half of patients seen by hospital doctors may be affected by medically unexplained symptoms [9]. Armed with this knowledge, psychologists theorised that these symptoms may be psychologically influenced, and developed psychotherapeutic treatments to address them. Research testing these treatments has been promising, and a recent review of these studies found that in all cases, psychological therapy reduced the severity of medically unexplained symptoms [10].

3. What common sense would suggest is a problem, isn’t always a problem

In healthcare, it can sometimes seem that there are a lot of things that need improving. Research can just be an added burden to this, an extra job on top of the normal clinical caseload. However, sometimes research can help reduce that to-do list, showing us that some things may be fine left unchanged.

A great example of this is research into interruptions on wards. The conventional view has long held that distractions and interruptions are a threat to patient safety. They take attention away from the task in hand and break clinicians’ concentration. However, research suggests that the real picture isn’t nearly so clear. Whilst interruptions in surgical settings have been linked with deteriorations in patient safety [11], research in ward settings has highlighted the benefits of being interrupted. For example, one study found that interruptions provided important information for staff, with 11% of them communicating knowledge that improved patient safety [12]. Other research has found that interruptions may help staff to stay alert by keeping them in a heightened state of arousal and eliminating boredom [12].

Taken together, these studies oppose the common-sense view that interruptions should be eliminated in ward settings and suggest that distractions are not always dangerous. Indeed, interruptions can keep clinicians alert and informed in some settings, and efforts to remove and reduce them could have unexpected consequences. Good news for clinicians – this is one thing that can be left unchanged!

4. What is common sense to clinicians isn’t always common sense to other people, and research evidence can lead to shared knowledge.

Part of our own research focuses on healthcare staff burnout, and we have found evidence suggesting that when staff are burnt out, safety and quality of patient care suffers [13]. In our discussions with healthcare staff we have been told that our research is obvious, common sense, and common knowledge. After all, anyone working on a ward can see that this is the case. However, gathering data demonstrating this link can help to explain and describe it to the public and policy makers, who may not fully understand the daily challenges of healthcare work. Conducting this kind of research can begin to quantify this association. For example, if a nurse is suffering from moderate burnout due to difficult working conditions, just how much is the quality of the care they can provide likely to suffer? We don’t have the answer to that one yet, but it’s these kind of questions we are keen to answer. We may be stating the obvious, but what seems obvious to you or me may not be so clear to everyone else.

So where now?

It seems pretty clear to us that research is necessary. It overturns false assumptions, finds strange new answers to problems, can help clinicians focus on the most pressing problems, and can justify the resources that clinicians need.

On the other hand, we are under no false illusions that the research process is perfect as it is. It can take years to secure funding for a project that is clearly needed, years more to undertake that project, and months more again until that research may be published and publicised. In the worst cases, by the time funding has been secured for a project, the landscape of the NHS has changed to such an extent that the project needs to be overturned entirely.

A need to improve the peer-review process

It seems to us that there is one clear place these time lines could be sped up: the peer-review process. Peer review is where grants and papers are critiqued by other researchers, and it can often take several months. The reason for this? Generally speaking, reviewers are not paid, and they provide these reviews anonymously. So highly qualified, busy professionals are expected to do this in their spare time, for virtually no personal gain whatsoever. In a pressurised work environment, this crucial work falls to the bottom of a long to-do list. To us, one obvious improvement could be to start incentivising reviewers. We’re seeing steps towards this with initiatives such as offering reviewers credits (reviewercredits.com; @reviewercredits), but more is needed here. There need to be tangible rewards for reviewing that will motivate reviewers to prioritise this task.

Time to build bridges

We also think there is clear potential for researchers and clinicians to work more closely together. Researchers may have research expertise, but they need the hands-on knowledge of clinicians to know where to apply this. On the other hand, clinicians may have the best ideas, but they need to reach out to researchers to help develop that all-importance evidence base.

References

  1. Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., Weatherall, M., & Beasley, R. (2009). Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart, 95(3), 198-202.
  2. http://www.clinmed.rcpjournal.org/content/11/6/628.2.full
  3. Brand, R. A. (2009). Clubfoot: Etiology and Treatment Ignacio V. Ponseti, MD, 1914–. Clinical orthopaedics and related research, 467(5), 1121-1123.
  4. Dobbs, M. B., Morcuende, J. A., Gurnett, C. A., & Ponseti, I. V. (2000). Treatment of idiopathic clubfoot: an historical review. Iowa orthopaedic journal, 20, 59-64.
  5. Ponseti, I. V., & Smoley, E. N. (1963). Congenital club foot: the results of treatment. J Bone Joint Surg Am, 45(2), 261-344.
  6. http://www.bbc.co.uk/programmes/b06zs22x
  7. Coomarasamy, A., Williams, H., Truchanowicz, E., Seed, P. T., Small, R., Quenby, S., … & Bloemenkamp, K. W. (2015). A randomized trial of progesterone in women with recurrent miscarriages. New England Journal of Medicine, 373(22), 2141-2148.
  8. Ko, J. K. Y., & Ng, E. H. Y. (2016). Scratching and IVF: any role?. Current Opinion in Obstetrics and Gynecology, 28(3), 178-183.
  9. Nimnuan, C., Hotopf, M., & Wessely, S. (2001). Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of psychosomatic research, 51(1), 361-367.
  10. van Dessel, N., Den Boeft, M., van der Wouden, J. C., Kleinstäuber, M., Leone, S. S., Terluin, B., … & van Marwijk, H. W. (2015). Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults, a Cochrane systematic review. J. Psychosom. Res, 78(628), 10-1016.
  11. Sevdalis, N., Undre, S., McDermott, J., Giddie, J., Diner, L., & Smith, G. (2014). Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World journal of surgery, 38(4), 751-758.
  12. Sasangohar, F., Donmez, B., Trbovich, P., & Easty, A. C. (2012, September). Not all interruptions are created equal: positive interruptions in healthcare. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 56, No. 1, pp. 824-828). SAGE Publications.
  13. Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O’Connor, D. B. (2016). Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PloS One, 11(7), e0159015.

This article was originally published on 31st August 2016 on healthprofessionalofinfluence.com (a now inactive website). 

5 Ways That Your Doctor’s Wellbeing is Important to You

[Authored by Louise Hall & Judith Johnson]

The NHS is rarely out of the headlines. Stories of growing waiting lists, breached targets and funding concerns abound. Some coverage has also considered the impact of these problems on NHS staff. Doctors have come forward to speak of the pressures of working long, antisocial hours in under-staffed, unsupportive environments. These articles have been met with scepticism by some – after all, aren’t doctors well-respected professionals working in modern healthcare facilities? And if things are tough for them, what has that got to do with us, their patients?

The real story

Truck drivers are forced to break every 4.5 hours for at least 45 minutes to prevent fatigue3, but doctors aren’t. In fact, doctors aren’t entitled to any break at all until they’ve worked for 6 hours, and then this break is only 20 minutes long. Despite the European Working Time Directive1 stating that the average number of hours a week must not exceed 48, this is actually spread across a 26 week time period, often resulting in doctors working in excess of 90 hours some weeks.

Although GPs hours may not be as long as those based in hospitals, their timetable is no less demanding. In addition to seeing as many as 40 patients a day, they make patient calls, house visits, and deal with all the paper work required to run a successful practice4. The average GP practice doesn’t have scheduled breaks, so staff are lucky if they have time for a proper lunch break or a rest from the intensity of continuously problem-solving patient cases.

The upshot

Research suggests that working such long hours, with such high levels of responsibility, takes its toll. A whopping 46% of GPs are classed as high risk for burnout5, and 30% of all healthcare staff have a minor psychiatric disorder, such as depression6-8. This is 11% higher than amongst the general population9.

So now let’s return to our second question: What has this got to do with us, their patients?

How doctor wellbeing affects patient care

  1. If your GP is unwell, you’re more likely to be referred, and your diagnosis delayed

Doctors that are suffering from burnout are more likely to refer you for additional tests. They realize they don’t necessarily have the mental resources to make a correct diagnosis, and may go overboard ensuring you’re checked for everything. Whilst this could be a sign of thoroughness, a doctor’s job is essentially weighing up risk and decision-making, and when they are functioning well they are able to make decisions on exactly which tests are essential. When these thought processes are impaired through poor wellbeing however, the additional tests you’re sent for will cost you time, requiring multiple visits back to the hospital/doctors surgery. These tests also inflict unnecessary costs on the health service, requiring resources that could be better used elsewhere10.

  1. Your experience of care will be poor

Burnt-out doctors are less likely to engage in patient-centered communication, which alongside making your appointments less enlightening is also associated with increased referral rates11. Additionally, a study found that patients of doctors who are burnt-out were less satisfied with their care than patients of doctors who had lower levels of burnout12.

  1. There’s more likely to be a mistake on your prescription 

The PRACtISe study in 2012 examined over 6,000 prescriptions within Primary Care and found that 1 in 20 prescriptions contained an error. That equated to 1 in 8 patients! Take a guess what one of the contributing causes to these mistakes was found to be…. Yep, you guessed it, the wellbeing of the GP. Anxiety, tiredness and physical wellbeing were all factors quoted by the GPs as causes for these mistakes. These factors are manifestations of heavy workloads, competing demands and time pressures that they are faced with daily13.

  1. If your doctor is unwell, they’re more likely to make a major medical error

“Medical errors” include things like wrong or missed diagnosis and wrong site surgery. Depressed, stressed, burnt-out, and anxious doctors are all significantly more likely to make errors than those who are psychologically healthy14-17. Which makes sense – if you’re not feeling well, it’s harder to concentrate. In fact it has been found that depression, for example, reduces cognitive functioning, which is important for our reasoning, memory, and attention systems18.

  1. Sick doctors cost you money

Doctors taking sick leave costs the NHS an average of £1.7billion each year19! But who foots this bill? We all do, in our taxes. And there’s no prize for guessing what one of the biggest contributors to sick leave in the NHS is: psychological wellbeing. Stress, depression, and anxiety account for more than a quarter of all sick leave. Worryingly, the level of stress seems to be only on the rise, with GPs reporting the highest levels of stress in Spring 2015 since the beginning of an ongoing survey that started in 199820.

So, next time that you think the welfare of our doctors isn’t your problem, think again. The healthier and happier the NHS staff are, the healthier and happier we all will be.

References

  1. http://www.bma.org.uk/support-at-work/ewtd
  2. http://www.heraldscotland.com/news/13126162.Revealed__junior_doctors_working_90_hours_a_week/
  3. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/208091/rules-on-drivers-hours-and-tachographs-goods-vehicles-in-gb-and-europe.pdf)
  4. https://www.healthcareers.nhs.uk/explore-roles/general-practice-gp/working-life
  5. Orton, P., Orton, C., & Gray, D. P. (2012). Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice. BMJ open, 2(1), e000274.
  6. Calnan, M., Wainwright, D., Forsythe, M., Wall, B., & Almond, S. (2001). Mental health and stress in the workplace: the case of general practice in the UK. Social science & medicine, 52(4), 499-507.
  7. Myers, H. L., & Myers, L. B. (2004). ‘It’s difficult being a dentist’: stress and health in the general dental practitioner. British dental journal, 197(2), 89-93.
  8. Wall, T. D., Bolden, R. I., Borrill, C. S., Carter, A. J., Golya, D. A., Hardy, G. E., … & West, M. A. (1997). Minor psychiatric disorder in NHS trust staff: occupational and gender differences. The British Journal of Psychiatry,171(6), 519-523.
  9. http://www.ons.gov.uk/ons/dcp171766_310300.pdf
  10. Kushnir, T., Greenberg, D., Madjar, N., Hadari, I., Yermiahu, Y., & Bachner, Y. G. (2014). Is burnout associated with referral rates among primary care physicians in community clinics?. Family practice, 31(1), 44-50.)
  11. Stewart M, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000; 49: 796–804
  12. Anagnostopoulos, F., Liolios, E., Persefonis, G., Slater, J., Kafetsios, K., & Niakas, D. (2012). Physician burnout and patient satisfaction with consultation in primary health care settings: evidence of relationships from a one-with-many design. Journal of clinical psychology in medical settings, 19(4), 401-410.
  13. Avery, T., Barber, N., Ghaleb, M., Franklin, B. D., Armstrong, S., Crowe, S., … & Serumaga, M. B. (2012). Investigating the prevalence and causes of prescribing errors in general practice. London: The General Medical Council: PRACtICe Study.
  14. Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Utility of a brief screening tool to identify physicians in distress. Journal of general internal medicine. 2013;28(3):421-7.
  15. de Oliveira Jr GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesthesia & Analgesia. 2013;117(1):182-93.
  16. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. Jama. 2009;302(12):1294-300.
  17. Niven K, Ciborowska N. The hidden dangers of attending work while unwell: A survey study of presenteeism among pharmacists. International Journal of Stress Management. 2015;22(2):207.
  18. Linden DVD, Keijsers GP, Eling P, Schaijk RV. Work stress and attentional difficulties: An initial study on burnout and cognitive failures. Work & Stress. 2005;19(1):23-36.
  19. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108910.pdf
  20. http://www.population-health.manchester.ac.uk/healtheconomics/research/Reports/EighthNationalGPWorklifeSurveyreport/EighthNationalGPWorklifeSurveyreport.pdf

A previous version of this article was originally published on 5th February 2016 on healthprofessionalofinfluence.com (now an inactive website).